Pulmonary Diseases in Pregnancy
Ma. Asuncion A. Fernandez, MD, FPOGS, FPSREISt. Luke’s College of Medicine WHQuasha MemorialNovember 9, 2009
OUTLINE
P Physiological changes
U Unclear, usual, ubiquitous conditions
L Lay back, launch out or limit care ?
M Model case
O Outcome
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 2
Ma. Asuncion A. Fernandez, MD, FPOGS, FPSREISt. Luke’s College of Medicine WHQuasha MemorialNovember 9, 2009
Physiologic
conditions
PHYSIOLOGIC CHANGES
Increased Decreased
Vital capacity Residual volume
Inspiratory capacity
Expiratory reserve volume
Tidal volume Functional residual capacity
Minute ventilation
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 4
RV + ERV = FRC
Except for residual volume and lung capacities derived therefrom, the ‘s can be measured using direct spirometric techniques.
PHYSIOLOGIC CHANGES
Sum of changes = Increased ventilation
Grounds breathing is deeper NOT more frequent
Goal basal oxygen consumption increased
Gestational result
Plasma pH Arterial PO2
PCO2
HCO3
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 5
Ma. Asuncion A. Fernandez, MD, FPOGS, FPSREISt. Luke’s College of Medicine WHQuasha MemorialNovember 9, 2009
Unclear
condition
UNCLEAR, USUAL, UBIQUITOUS
Dyspnea in Pregnancy
Common awareness need to breathe
Common complaint “shortness of breath” at rest = midpregnancy
Clarity of mechanism ?But attributed to
Alveolar hyperventilation
Response to substantively decreased PCO2
Consequence of anatomical changes in the thorax accompanying normal pregnancy
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 7
Ma. Asuncion A. Fernandez, MD, FPOGS, FPSREISt. Luke’s College of Medicine WHQuasha MemorialNovember 9, 2009
Usual conditions
UNCLEAR, USUAL, UBIQUITOUS
Diseases in Pregnancy
Pneumonia
Asthma
Tuberculosis
Sarcoidosis
Cystic Fibrosis
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 9
UNCLEAR, USUAL, UBIQUITOUS
Diseases in Pregnancy
Pneumonia Inflammation afffecting the lung parenchyma distal to the larger airways
Involving respiratory bronchioles, alveolar units
Broncho-pneumonia
Patchy and diffuse areas of involvement
No consolidation
Less severe form of pneumonitis
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 10
Complication: Preterm labor 20 poorly tolerated fetal hypoxemia and acidosis
UNCLEAR, USUAL, UBIQUITOUS
Diseases In Pregnancy
Bacterial Pneumonia
caught Inhalation nasopharyngeal secretionsAspiration
cause 2/3 Streptococcus pneumoniae
Mycoplasma pneumoniae
Influenza A
1/3 Indirect evidence ?Pneumococcal
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 11
UNCLEAR, USUAL, UBIQUITOUS
Diseases In Pregnancy
Bacterial Pneumonia
commonsymptoms
Cough, fever
Chest pain, dyspnea
Mild upper respiratory symptoms
Malaise
crucial for diagnosis
Chest x-ray
Coughed-up sputum (gram stain)
Serum, urine pneumococcal Ag
Serum mycoplasma-specific IgM
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 12
UNCLEAR, USUAL, UBIQUITOUS
Diseases In Pregnancy
Bacterial Pneumonia
counsel Hospitalization !
choice Erythromycin 500-1000mg q 6 hrs(pneumococci, mycoplasma)
Cefotaxime, ceftizoxime, cefuroxime (staphylococcal, haemophilus pneumoniae)
consider Persistent fever : Repeat C-Xray Thoracentesis
Thoracostomy tube drainage
Pneumococcal vaccine: (HIV,DM, CP, renal patients)
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 13
UNCLEAR, USUAL, UBIQUITOUS
Diseases In Pregnancy
Bacterial Pneumonia
complications Tracheal intubation
Mechanical ventilation
Empyema
Pneumothorax
Pericardial tamponade
Perinatal death
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 14
UNCLEAR, USUAL, UBIQUITOUS
Diseases In Pregnancy
Influenza pneumonia cause RNA viruses
caught Aerosolized droplets
Ciliated columnar epithelium, alveolar cells, mucus gland cells, macrophagesinfect
clinical course
2-5 days
complication Pneumonia Most common
Primary pneumonitis
Most severe form
Marks Sparse sputum production
Interstitial infiltrates CXR
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 15
Viral Pneumonia
UNCLEAR, USUAL, UBIQUITOUS
Diseases In Pregnancy
Influenza pneumonia check Swab cultures
Serologic confirmation
Seldom count: wbc >15000/ul
choice Amantadine (Category C) within 48 hours of symptoms
consider Influenza vaccine
Not routine
Nonetheless, ok for DM, CVD
No evidence: teratogenicity
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 16
Viral Pneumonia
UNCLEAR, USUAL, UBIQUITOUS
Diseases In Pregnancy
Varicella pneumonia cause Varicella-zoster virus (herpesvirus)
caught Chickenpox exposure sero(-) women
constitutional symptoms
Fever, maculopapular, vesicular rash; tachypnea, cough, dyspnea
clinical course
3-5 days
complication Strep / staph skin infection
Most common
Varicella pneumonia
Most serious form
Marks Chest pain, that’s pleuritic
CXR
Nodular infiltrates
Interstitial pneumonitis
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 17
Viral Pneumonia
UNCLEAR, USUAL, UBIQUITOUS
Diseases In Pregnancy
Varicella pneumonia choice Acyclovir 5-15 mg/kg intravenously
q 8 hours
consider CDC (Centers for Disease Control)
NOT included : Varicella-zoster immune globulin for exposed pregnant woman
Nonetheless: only given to immunocomprised
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 18
Viral Pneumonia
UNCLEAR, USUAL, UBIQUITOUS
Diseases In Pregnancy
Asthma cause (precipitating factors)
Allergens
Strenuous exercise
Aspirin
Respiratory infection
OB drugs: Fseries prostaglandins, ergonovine
characteristics(Hallmarks)
Bronchial smooth muscle contraction
Mucus hypersecretion
Mucosal edema
changes (biochemical effectors)
Primary mediators
Histamines
Secondary mediators
Prostaglandins, thromboxane, leukotrienes
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 19
UNCLEAR, USUAL, UBIQUITOUS
Diseases in
Pregnancy
Asthmacomplications fetal Preterm labor
Low birthweight infants
Abortion
Neonatal hypoxia
maternalLife-threatening
Status asthmaticus
Pneumo-thorax/mediastinum,
Acute cor pulmonale
Cardiac arrythmias
Muscle fatigue with respiratory arrest
correlation Maternal pulmonary funtion measurements
Birthweight
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 20
UNCLEAR, USUAL, UBIQUITOUS
Diseases In Pregnancy
Asthma compromise (fetal)
Combination of factors
MA TER N A L
Decreased uterine blood flow
Decreased maternal venous return
Alkaline leftward shift of the oxyhemoglobin dissociation curve
FETAL
Decreased umbilical blood flow
Increased systemic and pulmonary vascular resistance
Decreased cardiac output
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 21
UNCLEAR, USUAL, UBIQUITOUS
Diseases In Pregnancy
Asthma clinical course Broad spectrum
Mild wheezing
Severe bronchoconstriction
Airway obstruction
Decreased air flow
Chest tightness, wheezing, breathlessness
Respiratory failure
Severe hypoxemia
Death
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 22
UNCLEAR, USUAL, UBIQUITOUS
Diseases In Pregnancy
Asthma Clinical Stages of Bronchial Asthma
Stage PO2 PCO2 pH FEV1(% predicted)
Mild respiratory alkalosis
Normal 65-80
Respiratory alkalosis
50-64
Danger zone Normal Normal 35-49
Respiratory acidosis
<35
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 23
Barth & Harkins Modification 1991
UNCLEAR, USUAL, UBIQUITOUSDiseases In Pregnancy
Asthma Clinical evaluation
Subjective / severity inaccuratePatient’s impression
Physician’s clinical exam
Signs that help predict severity
Labored breathing
Tachycardia
Pulsus paradoxus
Prolonged expiration
Use of accessory respiratory muscles
Signs of a potentially fatal attack
Central cyanosis
Altered level of consciousness
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 24
UNCLEAR, USUAL, UBIQUITOUSDiseases In Pregnancy
Asthma Clinical evaluation
Objective / severity accurateArterial blood gas analysis
Assessment
Maternal oxygenation
Ventilation
Acid-base status
Pulmonary function testing
Are MOST useful tests
Monitor airway obstruction
FEV1 (forced expiratory volume in 1 sec)
PEFR (peak expiratory flow rate)
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 25
An FEV1 <1 L, <20% of that predicted,= severe disease = hypoxia, poor response to therapy, high relapse rate.
UNCLEAR, USUAL, UBIQUITOUS
Diseases In Pregnancy
Asthma Care Acute Asthma
Confinement: hospitalization
Hydration : intravenous fluids * help clear pulmonary secretions
Hand over supplemental oxygen by mask
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 26
UNCLEAR, USUAL, UBIQUITOUS
Diseases In pregnancy
Asthma Care Acute Asthma
Choice of pharmacological therapy
First line: B-adrenergic agonist
Epinephrine, isoproterenol, terbutaline, albuterol, isoetharine, metaproterenol
Function:Bind to specific cell-surface receptors and activate adenyl cyclase, which increases intracellular cyclic AMP to modulate bronchial smooth muscle relaxation
Frequently combined with corticosteroid
Onset of action several hours: whether IV or aerosol, should be given along with B-agonists
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 27
UNCLEAR, USUAL, UBIQUITOUS
Diseases In pregnancy
Asthma Care Chronic Asthma
Choice of pharmacological therapy
Theophylline
Aminophylline
Cromolyn sodium
Immunotherapy
Status asthmaticus
Condition : severe asthma of any type NOT responding after 30-60 minutes of intensive therapy
Indications for intubation / mechanical ventilation
CO2 retention, hypoxemia, fatigue
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 28
UNCLEAR, USUAL, UBIQUITOUS
Diseases In Pregnancy
Asthma Care Labor & Delivery
Steroids: been on it for the last 9 months? Corticosteroids: Give stress-dose
Selection of analgesic for labor? Choice: Fentanyl (nonhistamine- releasing narcotic) preferred than morphine or meperidine
Surgical delivery? Consider regional anesthesia than general anesthesia (intubation can trigger bronchospasm)
Suppose: refractory postpartum hemorrhage ? Compounds: PGE2 better than PGF2a
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 29
UNCLEAR, USUAL, UBIQUITOUS
Diseases In Pregnancy
Tuberculosis
cause Mycobacterium tuberculosis
characteristics Granulomatous pulmonary reaction
clinical manifestations
Cough, minimal sputum production
Low grade fever, hemoptysis, weight loss
CXRay Infiltrative patterns, cavitation, mediastinal lymphadenopathy
culture (+) patients
Acid fast bacilli = sputum stained smears
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 30
UNCLEAR, USUAL, UBIQUITOUS
Diseases In Pregnancy
Tuberculosis
care
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 31
Nonpregnant Tuberculin +, <35, no active
disease
• Isoniazid 300mg daily x 1 year
Pregnantasympto
matic
• Start after delivery• Withhold til after 12 weeks • Category C
UNCLEAR, USUAL, UBIQUITOUS
Diseases In Pregnancy
Tuberculosis
care
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 32
Nonpregnant active disease
• Isoniazid + rifampin +pyrazinamide
Pregnant active
disease
• Isoniazid 5mg/kg <300mg •Pyridoxine 50mg +•Rifampin 10mg/kg or ethambutol 15-25mg/kg
1st 2 mos
9 mos
Streptomycin : Category X in pregnancy: auditory, vestibular abnormalities, severe deafness
UNCLEAR, USUAL, UBIQUITOUS
Diseases In Pregnancy
Sarcoidosis
cause Chronic multisystem disease of unknown etiology (penumonitis, uveitis, erythema nodosum, lymphadenopathy)
characteristics Accumulation of T lymphocytes and phagocytes within noncaseating granulomas pulmonary reaction
clinical manifestations
Dyspnea
Dry cough
CXRay Interstitial pneumonitis (hallmark)
cure Prognosis good.Prednisone 1mg/kg OD x 4-6 weeks if still with inflammation
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 33
UNCLEAR, USUAL, UBIQUITOUS
Diseases In Pregnancy
Cystic Fibrosis
cause Serious genetic disorder; Pseudomonas aeroginosa (90%), S. aureus, H. Influenzae
characteristics Exocrine gland dysfunction,with production of thick viscid secretions; bronchial gland hypertrophy with mucous plugging and airway obstruction
clinical manifestations
Chronic bronchitis
bronchiectasis
Check “Sweat Test”; high Na, K, Cl
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 34
UNCLEAR, USUAL, UBIQUITOUS
Diseases In Pregnancy
Cystic Fibrosis
Complication & cure
Pregnancy discouraged
Pre-pregnancy counseling
Pancreatic insufficiency: oral pancreatic enzyme replacement
Cor pulmonale: bronchodilators, oxygen, and diuretics
Chest physiotherapy, nutritional support
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 35
Ma. Asuncion A. Fernandez, MD, FPOGS, FPSREISt. Luke’s College of Medicine WHQuasha MemorialNovember 9, 2009
Ubiquitous
condition
UNCLEAR, USUAL, UBIQUITOUS
Danger In Pregnancy
Carbon monoxide poisoning
cause CO: odorless, tasteless gas with high affinity and binding to hemoglobin
Inadequately ventilated areas warmed by space heaters utilizing natural fuels
characteristics Nonsmoker: saturation=1-3%Smoker: 5-10%Symptomatic: 20-30%Severe-fatal: 50-60%
Cure Hyperbaric oxygen
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 37
Half life of CO
Rm temp=4-6 hrs100% O2=1 hour Hyperbaric O2=15- 30 mins
Ma. Asuncion A. Fernandez, MD, FPOGS, FPSREISt. Luke’s College of Medicine WHQuasha MemorialNovember 9, 2009
Lay back, Launch,
Limit care
LAY BACK, LAUNCH OR LIMIT CARE?
Lay back Sarcoidosis treatment is the same for pregnant and nonpregnant. It has good prognosis and may heal spontaneously.
Launch Any pregnant woman suspected of having pneumonia should undergo anteroposterior and lateral chest radiography.
Management include: Prompt hospitalization, antimicrobial medications, and oxygen therapy when indicated.
Treatment of acute asthma during pregnancy is similar to that of the nonpregnant woman.
About one third of asthmatic women can expect worsening of disease at some time during pregnancy.
Monitoring the fetal response is an indicator or maternal compromise. Aggressively manage all pregnant women with acute asthma.
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 39
LAY BACK, LAUNCH OR LIMIT CARE?
Limit care?
In over 95% of patients, tuberculosis is contained and lies dormant for long periods . In some, it becomes reactivated to cause clinical disease. Know if the disease is active or inactive.
Carbon monoxide poisoning is almost everywhere. Both smokers and nonsmokers can be affected because of the high affinity of CO to hemoglobin.
Both the mother and fetus do not tolerate excessive CO inhalation. Treatment is supportive depending upon symptoms.
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 40
Ma. Asuncion A. Fernandez, MD, FPOGS, FPSREISt. Luke’s College of Medicine WHQuasha MemorialNovember 9, 2009
Model case
MODEL CASE
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 42
M.O.31 y/o G2P1
10 weeks AOG
No cough or hemoptysisAsymptomatic
Referred by pulmo:CXR: (+) PTB, activity ?
Outcome
Ma. Asuncion A. Fernandez, MD, FPOGS, FPSREISt. Luke’s College of Medicine WHQuasha MemorialNovember 9, 2009
OUTCOME
P Physiologic changes Vc Ic Tv Mv
RV+ ERV = FRC
U Unclear Dyspnea
Usual Diseases PATSC
Ubiquitous conditions Danger CMP
L Lay back Delay S
Launch Depart P, A
Limit care Direct T, CMP
M Model case Deal or No deal?
Patient O
Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 44
Pulmonary Diseases in Pregnancy
Ma. Asuncion A. Fernandez, MD, FPOGS, FPSREISt. Luke’s College of Medicine WHQuasha MemorialNovember 9, 2009